Education And Debate

Ethical issues in diagnosis and management of patients in the permanent vegetative state

BMJ 2001; 322 doi: (Published 10 February 2001) Cite this as: BMJ 2001;322:352
  1. Derick T Wade (, consultant and professor in neurological disability.
  1. Rivermead Rehabilitation Centre, Oxford OX1 4XD
  • Accepted 18 September 2000

Personal view p 372

Gastrostomy feeding has been withdrawn from around 20 people diagnosed as being in the permanent vegetative state in the United Kingdom, inevitably resulting in their death from dehydration. The clinical diagnosis is confirmed by healthcare professionals and legality is conferred by the courts, but the ethical position is not formally considered. This article outlines some specific ethical issues.

Summary points

The diagnosis of the permanent vegetative state cannot be absolutely certain

There is no standard test of awareness and data on prognosis are limited

Patients in the permanent vegetative state raise ethical issues concerning the nature of consciousness, quality of life, the value society attributes to life, and handling of uncertainty

In an era of increasing demands on healthcare resources decisions have to be made about allocation of limited resources and how quality of life is to be judged

Permanent vegetative state

The permanent vegetative state is diagnosed when a patient is unaware of himself or herself and his or her environment and there is no prospect of any change in this state by any means. The clinical characteristics and diagnosis of the condition have been established (box).16 Nevertheless, the clinical diagnosis is not always easy because there is a spectrum from the vegetative state to full awareness. The border between these two states is referred to as the low awareness state.1 No absolute definition exists for low awareness state. Generally, however, the patient behaves in a way that implies that at times he or she may be able to extract meaning from a stimulus and may be able to respond in a goal directed way. Usually the state is intermittent, with only vegetative responses being present at other times. Rarely, it may be possible to establish some form of rudimentary communication. We do not know if …

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